World Health Organization relesead the 2014 guidelines for Community management of opioid overdose.

Here are some highlights from the guidelines of particular relevance for emergency medicine

Formulation and dose of naloxone

Route of administration

The GDG recognizes that the IV route is appropriate and effective in medical settings

The capacity of the nasal mucosa to absorb liquids is limited, so if the intranasal route of administration is to be used, concentrated forms of naloxone should ideally be used.

The GDG has made this recommendation fully aware that the intranasal route is currently an off-label (non-licensed) route.

Affordability may dictate the preferred route in particular contexts

Dosage

The choice of initial dose will depend on the formulation of naloxone to be used and the context.

In medical settings dose selection is not generally an issue as dose titration is standard practice. In non-medical settings dose titration is not so easily accomplished and higher initial doses may be desirable.

The context also dictates the total amount of naloxone made available to non-medical responders.

The initial dose should be 0.4mg–2mg, targeting recovery of breathing. In most cases 0.4–0.8 mg is an effective dose. It is important to provide sufficient naloxone to supplement the initial dose, as necessary.

Intranasal delivery may require a higher dose. It should be noted that the commonly used method of intranasal administration is to spray 1 ml of the 1 mg/ml formulation of naloxone into each nostril with an atomizerconnected to a syringe.

Where possible, efforts should be made to tailor the dose to avoid marked opioid withdrawal symptoms. The GDG notes that higher initial doses above 0.8 mg IM/IV/SC are more likely to precipitate significant withdrawal symptoms.

A more complicated situation arises where there has been an overdose of a combination of drugs. In this situation naloxone is still beneficial for reversing the opioid intoxication component of the overdose.

Cardiopulmonary resuscitation

In suspected opioid overdose, first responders should focus on airway management, assisting ventilation and

administering naloxone.

Because the key feature of opioid overdose is respiratory arrest, ventilation is a priority. While recognizing there are different protocols in different parts of the world, the GDG suggests the following steps in resuscitating an individual with suspected opioid overdose.

In the presence of vomit, seizures or irregular breathing, turn the patient on their side, and, if necessary, clear the airway of vomit.

In the absence of regular breathing provide rescue ventilation and administer naloxone.

If there are no signs of life, commence chest compressions.

Re-administer naloxone after two to three minutes if necessary

In all cases call for professional assistance.

Monitor the person until professional help arrives.

Post resuscitative care

After successful resuscitation following the administration of naloxone, the affected person should have their level of consciousness and breathing closely observed until they have fully recovered.

The definition of ‘fully recovered’ is a return to pre-overdose levels of consciousness two hours after the last dose of naloxone.

Ideally, observation should be performed by properly-trained professionals.

The period of observation needed to ensure full recovery is at least two hours, following overdose from short-acting opioids such as heroin. It may be longer where a longer acting opioid has been consumed.

If a person relapses into opioid overdose, further naloxone administration may be required.

The definition of ‘fully recovered’ is a return to pre-overdose levels of consciousness two hours after the last dose of naloxone